Maintenance Care for Chronic Low Back Pain

A landmark study which was accepted in January, 2011 to be published in Spine looked at maintenance spinal manipulation therapy (SMT) for chronic, non specific low back pain (LBP) and whether there was a reduction of pain and disability levels over an extended period of time.  About 85 % of LBP patients who seek treatment are of a non specific variety, where there is a lack of underlying pathology (bone or nerve).  LBP is considered chronic when it has been present for over 12 weeks. 

The study was divided into three groups:  control (sham manipulation), SMT for one month, SMT for 10 months.  Treatment was given three times a week for the first month of the study, with patients in both the SMT groups reporting significantly lower pain and disability than the control group.  Following the second phase of treatment (10 months), patients who received bi weekly maintenance SMT had significantly lower pain and disability scores than those patients who did not have maintenance SMT.  Although the outcome measures for both the SMT groups were similar after one month, the non maintenance SMT group gradually returned to pre treatment levels (similar to the control group) by the end of 10 months. 

Not only did the maintenance SMT group who received care over 10 months have better results regarding their pain and disability levels than those patients who stopped care after one month, they also had improved lumbar mobility and better perceptions of general health.  This study supports what chiropractors have been saying to their patients for years.  Once the initial phase of treatment has been completed to stabilize your back condition, it is beneficial to consider monthly maintenance care to keep your spine functional and hopefully avoid acute episodes of back pain.

Lowering Cholesterol and Triglycerides with Supplements

 Elevated cholesterol and/or triglyceride problems are very common in modern society, and are known to increase risk for heart attack and stroke.  Dietary changes which reduce high fat animal products and consuming food high in fiber are beneficial, but many people are prescribed statins to further reduce their levels of cholesterol and triglycerides.  Unfortunately, these medications have side effects such as muscular pain and liver damage. 

There are two natural agents that have proven cholesterol and triglyceride lowering effects that can be used to complement dietary changes and can be taken safely in conjunction with statin drugs.  Gum Guggul is a resin from a tree native to India that has received prescription status in India in 1986 due to its high level of efficacy in human clinical trials in lowering cholesterol and triglycerides.  Human studies have demonstrated that guggulsterone, the active ingredient in gum guggal, can produce a cholesterol reduction of 14-27 % in 4-12 weeks, and a drop of 22-30 % of triglyceride levels.  A striking feature is its lack of toxicity and side effects, unlike cholesterol lowering drugs. 

Artichoke Leaf Extract is known to increase bile secretion by the liver, which clears more LDL cholesterol from the blood stream as cholesterol is the building block of bile acids.  In a double blind, placebo controlled study of 143 people with high cholesterol, artichoke leaf extract reduced cholesterol by 18.5% as compared to 8.6% in the placebo group, and LDL cholesterol dropped by 23% as compared to 6% to the placebo group; and LDL to HDL ratios declined by 20% vs. 7%. 

To be effective, Gum guggul must be standardized to 50-75 mg of guggulsterone per day, and artichoke leaf extract a minimum of 400 mg taken two to three times daily.  As with all supplements, results may vary, but there is a concrete way to determine if this is supplement is effective.  Have your cholesterol tested and then do a three month trial of Adeeva’s CholesterolEx or similar product and have a follow up cholesterol test.  

Laser Therapy in the Management of Neck Pain

Medical researcher Dr. Roberta Chow, MD, PhD was the lead author of a paper which summarized 16 clinical trials on Low Level Laser Therapy (LLLT) and the management of neck pain.  All the studies used LLLT of varying frequencies, and were double blinded, with either a placebo or control group.  A total of 820 patients were included in the research, which included both acute and chronic neck pain.    

Two trials showed an improvement in acute neck pain with the LLLT group over the placebo group.  Five trials showed an improvement in chronic neck pain with LLLT over the control group.  Eleven trials had a reduction of pain intensity that was statistically significant.  Seven trials involved follow up to 22 weeks after the treatment trial. 

There were mild side effects with LLLT group, but this was no different than with the placebo group. As with any therapy, individual results may vary, but overall the trials showed immediate pain reduction in the acute neck pain patients, and up to 22 weeks of reduced pain in the chronic patients post LLLT treatment.

Citation:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61522-1/fulltext#article-upsell

What a Pain in the Foot!

Summer time is upon us, and so often shoes are exchanged for flip flops.  The problem with flip flops is that they offer little support, and if you have abnormal foot mechanics such as flat feet, you can develop a painful arch, a condition called plantar fasciitis.   

 Plantar Fasciitis is caused by the breakdown and inflammation of collagen fibers in the thick band on the bottom of the foot that maintains the arch.  The pain can develop gradually over time with the most common symptom being pain in the morning or after prolonged sitting, as the band has shortened but limbers up after a few steps. Xrays may identify a heel spur, which is caused by the prolonged pulling of the plantar fascia from the heel. Secondary complications can develop as the difficulty in walking produces abnormal mechanics causing stress to knees, hips and the lower back.

Risk factors in developing plantar fasciitis include:

·         Increasing age as the ligaments are less supportive

·         Flat feet or high arches which causes faulty foot mechanics

·         Runners or ballet dancers who put abnormal stresses on the feet

·         Obesity and pregnancy places increased weight on the feet

·         Occupations which require prolonged standing

·         Improper shoes which lack arch support

Treatment includes:

·         Rest from activities that require being on the feet

·         Ice and oral anti-inflammatory (Aleve) or creams (Voltaren)

·         Laser, acupuncture or other modalities to increase healing

·         Massage therapy to relax and stretch the fascia and increase blood flow

·         Manipulation of a rigid mid foot to return normal function

·         Orthotics to support the arch and distribute weight for better mechanics

·         Exercises to stretch and strengthen the plantar fascia

·         Taping the arch to maintain support

·         Advice to avoid going barefoot, wear supportive shoes, and maintain a healthy weight

·         Severe cases may require steroid injections when unresponsive to conservative treatments but caution should be used as steroids weaken the collagen fibers

Often there is a combination of treatment that is required to be successful at keeping plantar fasciitis under control.  While individual results may vary, I have had success with laser treatments (approximately five), soft tissue stripping of the fascia of the arch, manipulation of the mid foot, and fittings with orthotics.  Home advice of using a 500 ml ice water bottle to offer both inflammation control and massage, as well as doing stretches also complement the therapy. 

So if you are finding you still want to wear your fancy summer shoes, take care of your feet so you don't develop that chronic pain in the foot!

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Low Level Laser Therapy in Treatment of Osteoarthritis of the Knee

A double blinded, randomized and controlled trial in patients with knee osteoarthritis was conducted to evaluate the efficacy of infrared low level laser therapy (LLLT) (also known as cold laser or therapeutic laser).  90 patients were randomly assigned to three treatment groups by a non-treating clinician.  The first group was given LLLT consisting of 5 minutes at 3 Joule dose, the second group was given LLLT consisting of 3 minutes at 2 Joule dose, and the third group was given placebo LLLT.  All groups were also given an exercise program.  Patients received 10 treatments and the exercise program was continued during the 14 week study.

Patients were evaluated with respect to pain, degree of active knee flexion, duration of morning stiffness, painless walking distance and duration, WOMAC Osteoarthritis Index scale.  Statistically significant improvements were made in all parameters such as pain, function and quality of life measure post therapy compared to pre therapy in both active laser groups.  Improvements in all parameters of the active laser groups as opposed to the placebo laser group were also statistically significant.  This study demonstrated that different dose and duration of laser therapy regimes were safe and effective for treating osteoarthritis of the knee.

Citation: Lasers in Surgery and Medicine33:330-338 (2003)

Manipulation or Microdiskectomy for Sciatica?

A 2010 clinical study compared the clinical efficacy of spinal manipulation against microdiscectomy in patients secondary to lumbar disc herniation.  Forty patients who met the criteria (failed at least 3 months of nonoperative management including treatments with analgesics, lifestyle modifications, physiotherapy, massage therapy and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. 

Significant improvements in both treatment groups compared to baseline scores were observed in all outcome measures.  After one year follow up, there did not appear to be a difference in outcome based on the original treatment received.  60% of the patients who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention.  Of the 40% left unsatisfied, surgical intervention conferred excellent results. 

The conclusion of the study was patients with lumbar disc herniation failing medical management should consider spinal manipulation followed by surgery if warranted. 

Citation: http://www.jmptonline.org/article/S0161-4754(10)00211-3/abstract

Canada's Costly Spine Surgeon Backlog

A May 13, 2011 Globe and Mail article written by Lisa Priest emphasized the waste and mismanagement in our health care system in regards to back pain.  Back pain is very common, with 80 % of the population suffering from a severe episode in their life.  Upwards of 85% of this back pain is diagnosed as mechanical or non specific back pain.  The small minority have more severe neurological or bony involvement, yet high tech tests such as MRI or CT are ordered by doctors, and with a 60% false positive rate, often find abnormalities that have nothing to do with the symptoms, but lead to a referral to a spine surgeon.

The unnecessary tests are leading to massive health care costs - $24 million a year in Ontario alone.  The avalanche of referrals has caused 60 of the 120 spine surgeons in Canada to close their practices to new patients at some point.  In an unscreened practice, upwards of 90% of the patients that attend a spine surgeon are not surgical candidates, creating a logjam for patients who truly need the referral and surgery. 

 Dr. Daryl Fourney of Saskatoon states that “the overwhelming majority of people with spine problems can be treated with physical treatments, whether it be exercises or spinal manipulation or medications”.  Dr. Fourney pioneered a program in Saskatchewan to train family physicians to discern which patients need to see a spinal surgeon.  There is an incentive built in, with access to diagnostic imaging and expedited surgical referrals for their patients.  The province has started to see a reduction in referrals to spine surgeons.

Hence the prescription to reverse the gridlock is a triage system, made up of primary care physicians, physiotherapists and chiropractors, to help differentiate patients who potentially need surgery.   Patients who then do not require a referral to a spine surgeon would be sent to other health care providers for treatment, and tracked to see if the treatments are working.  The Ontario government estimates this would require $3 million a year, but save the health system upwards of $20 million or more in unnecessary testing and referrals.